Approaches to Stroke Rehabilitation

Rehabilitation of Activities of Daily Living After Stroke

Activities of daily living (ADL) include feeding, grooming, dressing, bathing, toileting, transfers, and instrumental ADL's, such as home management and community living skills. Performance of ADL's requires visual, cognitive, perceptual, and coordination skills in addition to range of motion, motor strength, balance, sensation, and knowledge of culture, caregiver roles, and discharge environmental concerns. Physical strength and balance in the elderly positively correlates with independence in instrumental ADL's. Therapists evaluate performance skills, identify problems that interfere with independence, establish goals, and provide training and equipment to maximize independence. Standardized ADL checklists, interviews, and performance evaluations establish baseline function.

Arm and leg management is crucial for successful rehabilitation of ADL dysfunction. Splints reduce abnormal tone and prevent deformity. Orthotic management of the wrist, elbow and knee reduces risk of contracture and increases potential for functional performance. Elevation of the hand above the heart, range of motion exercises, retrograde massage, air splints, pressure wrapping, and icing reduce edema. Purposeful activities increase balance and arm movement more than repetitive exercises. Stroke survivors learn how to compensate for sensory deficits through visual cues and use of supports.

Traditional methods used to teach ADL's include demonstration, verbal instruction, environmental adaptations, one-handed techniques, adaptive equipment, simplification of tasks, positioning, and movement facilitation. Evaluations of ADL performance may be simulated in the rehabilitation unit or applied in a therapeutic home visit. Constraint-induced movement therapy may be used to retrain the stroke survivor in selected ADL skills.

Driving

Deficits in strength, coordination, vision, perception, and cognition may limit the stroke survivor's safety in driving. Occupational therapists perform a driver's evaluation which includes a medical history and assessment of vision, muscle and grip strength test, brake reaction time, and perceptual and cognitive abilities. Driving skills are tested in a simulator or behind-the-wheel with an instructor. Adaptive aids, such as steering wheel pegs and accelerator extensions, may be incorporated to compensate for motor deficits. Training in visual scanning and tracking, reaction time, spatial perception and execution of complex actions may be required for successful completion of driver training.